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SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City JP Lot Size/Acreage PEtM 41APtLA!!1-- T / C) -5T- Owner's Name Address � r/� I:nl / �+Q'7_9QPPhone Contractor 442, Address 0i /GfJ��3� License foto 5_ Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service knell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. T PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ i Specifications i'l Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout - W I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by V% Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITIQN I I DESTRUCTIONXI (No septic system permitted if public sewer is r �. .available within 200 feet.l Installation will serve: Residence_ Commercial-Z Other e Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth `r 5 SEPTIC TANK. ❑ Type/Mfg �-� Capacity No. Compartments PKG. TREATMENT PLT.0 'A,1 r4 F7- Method of Disposal Distance to nearest: Well Foundation�_ Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for I required inspections. Complete drawing on reverse side. Signed X Jr 142011Title: Date: �/f FOR DEPARTMENT USE ONLY Application Accepted by "� Data 1 f` 1 Area �l U Pit or Grout Inspection by Date Final Inspection by Date g Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE' AMO NT DUE AMOU T RFMITTEO INFO RECE EU BY ATE PERMIT NO. • EH 13.24(REV.1/n 5) 6b ' /p ' EH 11.2E �l